Submission Errors

Part B Provider Outreach and Education January 2015

Webinar Protocol • Cannot register with WebEx using mobile device

– Must use desktop or laptop • When entering/throughout workshop – all lines muted • Presentation emailed 3 days before webinar

– Adobe PDF format (with printing instructions) • Throughout webinar

– Questions pertinent to the webinar slide addressed – Address Q & A to “all panelists”; not to host directly – All other questions, call Part B Provider Contact Center

• Webinar conclusion – Asking questions aloud? Use “raise/lower hand” feature – MUTE phones – never place on HOLD

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Using WebEx During Workshop

Participants •Option to ask a question at the end of workshop •Use the raise/lower hand feature •Once question answered, lower the hand

Chat •Not included as registered for this workshop? •Enter name, office & city/state in this section •Keeps track of attendance for you, AAPC and Noridian

Q&A •Have a question during workshop? •Type question in box and send to all panelists, not host •Noridian staff will respond to questions in order •Keep questions to topic/previous slides discussed today

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Continuing Education Unit (CEU) • When registering, add additional attendees

– First and last names • Attend entire webinar

– Optional to stay for Q/A • Take short polling survey

– After closing out of webinar • CEU emailed 3 days after presentation

– Earn between .5 and 1.5 CEUs – No password or index number needed – All providers use CEU certificate

• Certificate of Attendance no longer available

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DISCLAIMER

This information release is the property of Noridian Healthcare Solutions, LLC (Noridian). It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents.

The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice.

All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the information contained in this release can be found on the Noridian website at http://www.noridianmedicare.com and the CMS website at http://www.cms.gov

The identification of an organization or product in this information does not imply any form of endorsement.

CPT codes, descriptors, and other data only are copyright 2015 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

Agenda

• Reducing Submission Errors • Remittance Advice (RA)

– Common Denial Messages • Reopening / Resubmission / Redetermination • Written Correspondence Tips • Resources

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Objective

• To avoid or reduce unnecessary referrals, appeals and other form submission errors

• When it’s appropriate to resubmit claims, call reopenings and fax redeterminations

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ACRONYM DESCRIPTION ABN Advance Beneficiary Notice of Non Coverage

CCI Correct Coding Initiative

CERT Comprehensive Error Rate Testing

CR Change Request

IOM Internet Only Manual

MLN Medicare Learning Network

MPFS Medicare Physician Fee Schedule

MSP Medicare Secondary Payer

OIG Office of the Inspector General

PECOS Provider Enrollment Chain & Ownership System

RA Recovery Auditor

January 2015 8

Reducing Submission Errors

Unprocessable Claims

• Rejected claim or MA 130 denial – Claim contains incomplete/invalid information – No appeals rights - claim unprocessable – No reopenings

• Fix error(s) and resubmit – Resubmit new electronic or CMS-1500 claim – Do not indicate “corrected” claim

10 January 2015

Avoiding Unprocessable Claims Internal Steps

1. Know fee schedule indicators/descriptors 2. Check patient’s Medicare card

– Ensure billing exact name and HIC # 3. Ask patient

– If any primary insurances to Medicare (auto, disability, working spouse, etc.)

• Possible MSP

4. Need valid ordering/referring provider NPI – Check PECOS if enrolled

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1. Fee Indicator

•Link to indicator list •Search CPT - Ctrl+F •Check descriptors for explanations •Next slide shows all indicators involved

•E.g. multiple surgeries, bilateral, assistant, etc.

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JF

JE https://med.noridianmedicare. com/web/jeb/fees-news/fee-schedules/mpfs

https://www.noridianmedicare.com/partb/fees/docs/2014/2014_mpfs_indicator_list.pdf

January 2015 13

Fee Schedule Indicators

•Variety of workshops archived if need to learn about •New Provider/Biller, Claim Submission, MSP, ABN, Payment Notices/Reimbursement, Appeals, Modifiers, CCI-MUE, etc.

•JF Education Center – Workshop Archives https://www.noridianmedicare.com/partb/train/workshops/archive.html •JE Workshops, Materials and Prior Events https://med.noridianmedicare.com/web/jeb/education/event-materials

Fee Schedule Descriptors

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January 2015

2. Patient’s Name/HIC# Must Match

15

3. Item 11 (possible MSP?) DENIAL SOLUTION COMMENTS

CO16 Claim/service lacks information which is needed for adjudication

Add NONE (if no primary insurance to Medicare)

•Verify Primary Insurance information •Verify patient’s eligibility before billing

MA83 Did not indicate whether Medicare is primary or secondary payer

•If Medicare Secondary Payer (MSP), MUST fill out items 11 – 11C •Check dates of service correctly entered •NONE (if no primary)

•MSP incorrect? •NEW Benefits Coordination and Recovery Contractor - BCRC •855 798 2627

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4. Item 17/17B Ordering/Referring • Missing, incomplete or invalid name information • Search NPI website for physician’s name listing at

https://npiregistry.cms.hhs.gov/NPPESRegistry/NPIRegistryHome.do

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Denial Description Possible Issue Correction CO16 Claim/service lacks

information needed for adjudication

NPI/referring provider name Item 17/17B missing

Reflect correct last/first name and NPI of referring/ordering

N264/ N265

Missing/incomplete/invalid ordering provider primary identifier/name

Incorrect/invalid NPI number not matched to name on file

Confirm Medicare enrollment for ordering provider and correct information

N286 Missing/incomplete/invalid referring provider primary identifier

Item 17 name invalid •E.g. Becky Orders (First, Last Name)

Item 17 must be Last Name, First Name •E.g. Orders Becky

Correct Frequencies

• Check patient’s eligibility – Has enough time passed since last service?

• E.g. G0101 was performed before next eligible screening pelvic exam

– Is this a “Once in a Lifetime” procedure? • E.g. G0402 – Initial Preventive Physical Exam

(IPPE) • Allowed only in the first 12 months of beneficiary

Medicare enrollment

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Remittance Advice (RA)

When RA Received

• Bill beneficiary’s secondary health plans – Possibly auto-crossed over by Medicare

• Quickly identify potential problems – Correct errors with original claim – Avoiding same errors – Checking adjustment reasons

• Need Reopening to fix clerical error? – Wait 3 – 5 business days after RA date,

before calling Phone Reopenings

January 2015 20

Reason/Remark Codes • Washington Publishing Company (WPC)

– http://www.wpc-edi.com/codes • Reason/Remark Codes Listing (PR, CO, OA) • Scroll down to code lists

– Claim Adjustment Reason Codes (CARC) – Remittance Advice Remark Codes (RARC) – Claim Status Codes – Claim Status Category Codes

• Distributed, maintained and updated by WPC – Three times per year (March, July and

November)

January 2015 21

Common Errors- Claims Page • Noridian Error Reason

Codes/Explanations JF

– https://www.noridianmedicare.com/partb/train/education_center/claim_submission.html

JE – https://med.noridianmedic

are.com/web/jeb/topics/claim-submission/errors-omissions-solutions/reason-code-guidance

January 2015 22

CO16 Claim/service lacks information needed for adjudication

•Invalid item 3, 11, 17, 32 CO50 Non-covered services not deemed

“medical necessity” by payer •Assistant surgeon not eligible

CO109 Claim not covered by this contractor •Managed Care/Part A/Railroad

January 2015

Contractual Obligation (CO)

CO = provider responsibility • Cannot bill patient or secondary insurance

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Patient Responsibility (PR)

PR45 Charge exceeds fee schedule, maximum allowable or contracted-legislated fee arrangement • Assigned provider not affected • Non-assigned provider must refund patient

PR96 Non-covered charge(s) • Traction, x-rays, etc. by Chiropractor

PR117 Transportation covered to closest facility that provides necessary care • Ambulance transport for convenience to further hospital (family/patient request)

January 2015 24

Correct Procedure vs. Modifier

• CO4 – Procedure code inconsistent with modifier or

required modifier missing • Confirm that modifier is applicable; e.g.

– Modifier 76 invalid with E/M or Ambulance – Modifier 25 only applicable with E/M codes

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Reopening vs. Resubmission vs. Redetermination

Which to Send…..

Reopening vs. Redetermination • Reopening

– Think clerical errors/omissions • Left off modifier, transposed date of service, place of service

(POS) incorrect, etc. – Can not call reopenings for:

• Recovery Auditor (RA) requests, recoupment issues, Medicare Secondary Payer (MSP) or timely denials

• Redetermination – Need documentation to support appeal – Check correct box (CERT, RA, etc.)

• All Noridian forms interactive • Don’t forget to sign!

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Written Reopening – JE https://www.noridianmedicare.com/je/partb/forms/nhs_reopen_sample.pdf

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Written Reopening – JF https://www.noridianmedicare.com/partb/forms/docs/nas_reopen_sample.pdf

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Redetermination Form – JE https://www.noridianmedicare.com/je/partb/forms/nhs_redeterm.pdf

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•Sign, date and check correct box •CERT, RA, Redetermination, WIC •Faxing preferred

Redetermination Form – JF https://www.noridianmedicare.com/partb/forms/redeterm.html

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•Sign, date and check correct box •CERT, RA, Redetermination, ZPIC

•Faxing preferred

Signature

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• ALWAYS SIGN forms to Noridian • Appeals can not review if missing • Medical documentation submitted

• Needs proper provider signature(s) • Speeds up process for quicker payment

Recoupment/Refund Forms 1. Immediate Recoupment

– Noridian prefers form faxed @ 701-277-7874 – Includes one-time overpayment, all future

overpayments or never utilize immediate recoupment – Request specific overpayment in demand letter

2. Refunds to Medicare MSP – Same form for both JE/JF providers – Cannot fax - separate mailing to Los Angeles, CA

3. Refunds to Medicare Non-MSP – Same form for both JE/JF providers – Cannot fax - separate mailing to Los Angeles, CA

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1. Immediate Recoupment • “Immediate Recoupment” process – CR7688 • Must be signed by Provider/CEO/CFO

– Not processing without one of their signatures – Noridian does not accept typing or initials

• Reflect letter # from demand letter received – Upper right hand corner – no transaction

numbers • Aggregate accounts less than $25.00

– One A/R per Invoice • Demand overpayments only

– Use refund forms for voluntary refunds January 2015 34

Immediate Recoupment – JE https://www.noridianmedicare.com/partb/forms/docs/i

mmediate_recoupment_request.pdf

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Immediate Recoupment – JF https://www.noridianmedicare.com/partb/forms/docs/

immediate_recoupment_request.pdf

January 2015 36

MSP Refund Form – JE PO Box 511381 (similar to JF)

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MSP Refund Form – JF

PO Box 511359 (similar to JE)

January 2015 38

Non-MSP Refund Form – JE https://med.noridianmedicare.com/web/jeb/forms

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Non-MSP Refund Form – JF https://www.noridianmedicare.com/partb/forms/docs/refund_form.pdf

January 2015 40

Medical Review (MR) Reminders

• Inappropriate to resubmit claims – If no payment/denial received

• MR has up to 60 days to review pending claims – Medical necessity denial

• Must appeal – do NOT resubmit claim – Duplicate denial

• Find original denial message and correct billing

• Resubmission overwhelms payment systems – If office software set up to auto rebill frequently,

work with vendor to reset at 60 days

January 2015 41

Duplicate Claim Submission

• Inappropriate to resubmit claims/appeals – MR has up to 60 days to review pending claims – Medical necessity denial

• Must appeal – do NOT resubmit claim – Duplicate denial

• See original denial and either resubmit corrected new bill or appeal

• Resubmission overwhelms payment systems – If office software set up to auto rebill frequently,

work with vendor to reset at 60 days

January 2015 42

Submitting Duplicate Claims • May lead to or may result in

• Payment delay • Identifying practice as abusive biller • Triggering fraud investigation

• If pattern of duplicate billing established • IOM 100-04, Chapter 1, Section 120

“Detection of Duplicate Claims” • Read CR 8121 effective April 2013

• https://www.noridianmedicare.com/partb/news/bulletins/docs/medicare_b_news_issue_286_june_2013.pdf

January 2015 43

Written Correspondence Tips

General Written Correspondence • Do NOT use this form for

– MSP, Recoupment, Rebilling, Redetermination or Reopening requests

• Additional Documentation Letter (ADL)? – Include ADL as cover letter – Every medical record/documentation page must

contain beneficiary first/last name • Why is request sent?

– Is this a true Written Inquiry? – Noridian does NOT accept faxed new/initial

claim form submission

46 January 2015

JE Written Inquiry

https://www. noridianmedicare.com/partb

/ forms/

January 2015 46

JF Written Inquiry

https://med.noridianmedicare.com/web/jeb/

forms

January 2015 47

Top Return/Dismissal Reasons 1. Incomplete Provider Inquiries

– Not indicated/explained what was needed – Left out necessary authentication info

2. Duplicate inquiries or appeals – Do NOT resend previous appeals/inquiries

3. Unprocessable claims are not appealed 4. Beneficiary in HMO/MA plan 5. General Written Inquiry form check boxes

– Left off or incorrectly checked

49 January 2015

Resources

Receive Part B CERT Request?

• CERT post pay audit review random documentation sampling on previous claims

• Need Part B assistance? Please email: – Patty.Holton@noridian.com or

CERTQuestion@noridian.com • Follow email steps:

– “Subject” line enter CERT Claim Identification (CID#) (seven-digit number starting with “1”)

– “Body of email”, provider office contact information (name, phone/fax number, CID#, city/state)

January 2015 50

Noridian CERT Checklists • Use as guideline to include documentation • JE

– https://med.noridianmedicare.com/web/jeb/cert-reviews/cert/checklists • JF

– https://www.noridianmedicare.com/partb/claims/cert/index.html

• Ambulance • Chiropractic • Dialysis • Evaluation and Management (E/M) • Laboratory • Physical, Occupational and Speech Therapies • Psychiatric-Mental Health • Radiation Oncology • Radiology

January 2015 51

CMS Educational Materials • MLN products downloadable

– Free of charge/free shipping • Brochures • Fact sheets • Quick reference charts • Web-based training

MLN dedicated web pages • MLN General Information

http://www.cms.gov/MLNGenInfo • MLN Matters Articles

http://www.cms.gov/MLNMattersArticles • MLN Products

http://www.cms.gov/MLNProducts • MLN Web Guides

http://www.cms.gov/MLNEdWebGuide

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MLN Brochures

October 2010 NAS LLC Proprietary

Medicare Provider Compliance

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• http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MedQtrlyComp-Newsletter-ICN909051.pdf

• Quarterly Newsletter – Includes RA findings – Co-surgery – Pre-admission

diagnostic testing – Duplicate claims – Mohs surgery – Cataract surgery – E/M services

In Summary • Use Noridian/CMS website tools

– Attend webinars like this presentation – Read Medicare emails and articles – Utilize Noridian calculators for timeliness – Follow CMS MLN fact sheets

• Use correct forms when requesting appeals or submitting overpayments, etc. – Refund forms depend on “solicited or voluntary” – Reopening/Redetermination/Resubmission

• Continue the excellent job of quality and service provided to Medicare beneficiaries!

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CEU Process Reminder

• When registering, add additional attendees – First and last names

• Attend entire webinar – Optional to stay for Q/A

• Take short polling survey – After closing out of webinar

• CEU emailed 3 days after presentation – Earn 1.0 CEU today! – No password or index number needed – All providers may use CEU certificate

• Certificate of Attendance no longer available

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Thank you!

Questions?

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